Approach to inborn errors of metabolism (acute) Quiz: Ace Your Exams

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A 6-day-old boy is admitted to the hospital with fever, difficulty feeding, and jaundice. The infant was delivered via spontaneous vaginal delivery at 39 weeks' gestation. Pregnancy and delivery were uneventful. The infant is breastfed and has appropriate wet diapers and bowel movements. Family history is non-contributory. Newborn screen results are pending. Temperature is 38.2°C (100.7°F), pulse is 155/min, respirations are 35/min, blood pressure is 80/45 mm Hg, and oxygen saturation is 96% on room air. On physical exam, the infant is hypotonic, and hepatomegaly is noted. The anterior fontanelle is open and flat. Cardiopulmonary exam is normal. Maternal and infant blood types are both A positive. Laboratory studies reveal direct hyperbilirubinemia and elevated transaminase levels. Blood culture is positive for Escherichia coli. Which of the following physical exam findings is associated with this condition?

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